Resolution of urinary symptoms following pelvic venous disorder treatment

INTRODUCTION

If up to 30% of chronic pelvic pain is caused by pelvic venous disorders (PeVD), then as high as 8% of women may experience some form of this condition.^[1] To standardize discussion of PeVD, the Symptoms-Varices-Pathophysiology classification by the American Vein and Lymphatic Society International Working Group on PeVDs has gained popularity since its publication in 2021.^[2] Part of the impetus for this classification is the wide variety of symptomatic presentations depending on the various venous reservoirs affected by this condition; whether it be driven by left ovarian venous reflux, left common iliac compression, or a combination of venous pathologies. Diagnosing and recognizing PeVD continues to be a clinical challenge. Helpful signs and symptoms continue to be pelvic fullness or pain worsening throughout the day while upright, along with associated pelvic and/or leg varicosities.

However, what if the conditions that make up the other 70% of etiologies responsible for chronic pelvic pain are also related to pelvic venous pathology? This would mean that the prevalence of misdiagnosed or undiagnosed PeVD could be even higher. In this context, interstitial cystitis (IC) is another cause of pelvic pain in women with a prevalence ranging from 2.7 to 6%.^[3] In 2018, a study on rats simulated pelvic venous congestion by ligating the common iliac veins. Researchers then performed cystometry as well as histology and found that rats with PeVD had increased urinary frequency, decreased bladder blood flow, and increased bladder wall inflammation.^[4] Due to this study, the authors hypothesize that there is some relationship between IC and PeVD.

To assess the relationship between PeVD and IC, a retrospective analysis of patients with urinary dominant symptoms as well as pelvic venous congestion was performed to assess for urinary symptom resolution following treatment of venous pathology.

MATERIAL AND METHODS

A retrospective case review of patients with urinary symptoms and concomitant findings of PeVD treated with either iliac vein stenting or gonadal vein embolization was performed evaluating patients from 2019 to 2023 at a single institution. This paper is approved under the institution’s Institutional Review Boards umbrella policy for retrospective studies. This study adheres to and is in accordance with the Code of Ethics of the World Medical Association. During the period in question, 206 pelvic venograms were performed. Of these, approximately 60 were specifically for PeVDs. Male varicocele embolization patients were excluded from the study. Female patients included in this analysis were those who had a diagnosis of IC from prior urology evaluation or urinary dominant symptoms such as recurrent urinary tract infections, dysuria, and pelvic pain without the official diagnosis of IC. The diagnosis of concomitant pelvic venous congestion and/or reflux was confirmed by venography in the preoperative or intraoperative period. Outcomes were determined by patient self-reported symptoms in clinic follow-up 1–6 months following intervention.

RESULTS

Based on inclusion and exclusion criteria, 7 female patients (5 with IC) with an average age of 43.3 years met the criteria for inclusion. Of these, three patients demonstrated venography findings of iliac compression including retrograde filling of the internal iliac veins and parametrial venous plexus as well as venous compression on intravascular ultrasound (IVUS) >60% [Figures 1 and 2]. Following diagnosis, these women received left common iliac venous stents, most commonly Abre (Medtronic Plc, Minneapolis, Minnesota, USA) self-expandable venous stents [Figure 3]. Technical success was defined as appropriate stent apposition to the venous lumen, minimal residual stenosis on IVUS, and resolution of retrograde flow into the internal iliac venous system.

Close

Figure 1:

A 57 year old female, left external iliac venography from the right internal jugular approach with retrograde flow into the left internal iliac vein.

Export to PPT

Close

Figure 2:

A 57 year old female, intravascular ultrasound of the proximal left iliac vein showing luminal narrowing of 61%.

Export to PPT

Close

Figure 3:

A 46 year old female, venography following left common iliac self-expanding nitinol stent placement with resolution of retrograde flow.

Export to PPT

The other 4 patients demonstrated venographic findings of left ovarian reflux including static and/or regurgitant flow. Following diagnosis, these women received left ovarian vein embolization, most commonly with Nestor (Cook Medical Inc., Bloomington, Indianapolis, USA) 0.035 pushable coils. Technical success was defined as venography demonstrating resolution of regurgitant flow and was achieved in each of these patients. All of these patients demonstrated antigrade flow through their right ovarian vein. Therefore, no right ovarian vein embolizations were performed.

Following treatment, all five of the patients with IC had complete resolution of IC-related symptoms within 5 months (average of 1.9 months). Both remaining patients with urinary dominant symptoms without a diagnosis of IC had complete resolution of symptoms at 1-month follow-up. One IC patient received hydrodistension following treatment, but her symptoms have not recurred despite being outside of the 6–9 months therapeutic window for this treatment.^[5]

DISCUSSION

Stenting for left iliac venous compression and embolization of left ovarian venous reflux led to urinary and IC symptomatic resolution, the primary outcome of this paper, in all seven patients that met inclusion criteria for this retrospective review.

Due to the multiple venous reservoirs in PeVD, the variable treatment patterns among interventionalists, the variable presentations among patients, and the relative paucity of prospective research on this condition, it can be hard to account for multiple confounding variables in treating and evaluating this condition which limits this study. Furthermore, this is a small group of patients reviewed retrospectively from a single center without a control group.

Regarding differences in technique, some interventionalists embolize the right gonadal vein when treating PeVD regardless of flow if it is enlarged. This contrasts with our approach. At our institution, we do not embolize veins with antigrade flow because this would disrupt a functioning venous drainage pathway from the pelvis. We hypothesize that the dilation of the right ovarian vein is due to the increased blood flow that it receives in the setting of left ovarian venous reflux.

Based on literature review, this correlation between venous symptoms and PeVD has not been studied outside of the referenced rat model, making comparison to other studies difficult. This paper stands as the first evidence in humans that there is a possible connection between PeVD and IC beyond this rat model. Ideally, this possible connection will fuel further evaluation and research. A prospective study randomizing patients to treatment, control, and/or sham procedure is needed to further assess this connection. Assessment of symptoms should continue to be the primary endpoint of this evaluation, but supplemental bladder histopathology before and following intervention would be useful to compare to the findings in the rat model including evaluation of decreased bladder wall blood flow and increased inflammation.

CONCLUSION

In this small case series, the treatment of PeVD led to the resolution of IC symptoms and urinary dominant symptoms in the treated patients. This supports a prior study in rats demonstrating bilateral common iliac venous ligation to simulate pelvic venous hypertension is associated with urinary frequency, decreased bladder blood flow, and increased bladder wall inflammation. Prospective randomized controlled trials and larger retrospective analyses are indicated to evaluate the relationship between urinary symptoms (including IC) and PeVD syndrome further.